VIFM CLINICAL FORENSIC MEDICINE

Confidential Forensic Medical Report

Sexual Assault

Date report prepared: Date

Report prepared for

RankInformant's Name

Police Unit

DX or Address

REName: Patient Name

Date of Birth: Patient DOB

Author of report: Authors Name

I, Doctor/Nurse Name am a duly qualifiedMedical Practitioner/Reg Nurse (Div 1) registered in Australia. I am a Position Title employed by the Victorian Institute of Forensic Medicine at 57-83 Kavanagh Street, Southbank, Victoria. My further qualifications and experience include:

Qualifications and experience

Qualifications and experience

Qualifications and experience

Qualifications and experience

Reason for Assessment

Requesting Agent Given NameRequesting Agent Surname Name from the Police Unit, DX or Address police contacted me at Date & Time Received requesting a forensic examination on Patient Name following an incident that occurred 0 hours ago. The police requested documentation of injuries, photographs and collection of forensic specimens in this case.

Site and time of assessment(s)

I examined Patient Namea xx year old male/female at the Examination Location on theExamination Commencement Date and time.Patient Name was accompanied by accompanying person and/or police officer(s).

Consent

Name of person providing consent provided consent for the history,examination,collection of forensic and medical specimens and documentation of findings, photographyand release of a medico-legal report to police, for research purposes

manner, use of forms to obtain consent, limitations in obtaining consent

Observers

Name/s of observerwas/were present during the taking of the history.

Sources of information

The following information was provided by Police Officer's name at the time of the consultation:

------

History

A history to guide the examination was taken from Patient Name who stated the following:

Patient History

On direct questioning, Patient Name told me:

Symptoms, condom, bathing, ejaculation, other forms of penetration, relevant negatives

The above history was taken in order to direct the examination and does not necessarily constitute a detailed account of the entire event.

Past Medical History

A past medical history was taken - and of relevance to the case and my opinion was....., OR - and contained no relevant information the case or my opinion

Examination

Patient Name was examined in the presence ofList those present. The examination was conducted approximately xxx hours following the incident. The examination encompassed the entire body or was restricted to the following areas because....

general appearance and relevant negatives regarding intoxication, psychiatric, symptomatology, intellectual or physical disability

Head and Neck

  1. 1.

Back and Buttocks

  1. 2.

Chest and Abdomen

  1. 3.

Right Upper Limb (hand, forearm, arm)

  1. 4.

Left Upper Limb (hand, forearm, arm)

  1. 5.

Right Lower Limb (thigh, leg, foot)

  1. 6.

Left Lower Limb (thigh, leg, foot)

  1. 7.

(Indicate any sites not examined)

Genital Examination

A genital examination was conducted and revealed the following findings:

normal mature female/male genital anatomy

------

------

A speculum examination was conducted and revealed

-OR-

A speculum examination was not conducted due to patient's wishes and/or the circumstances of the case.

-AND-

Or, a genital examination was not conducted at the time of the examination due to patient wishes and the circumstances of the case.

Photographs

There were no photographs taken at the time of the examination.

-OR-

Photographs were taken at the time of the examination by Photographer.

-AND-

A bound set of photographs accompany this report -OR- are contained within this report.

Forensic Specimen Collection

The following forensic specimens were collected at the time of the examination:

  1. ------
  2. ------
  3. ------
  4. ------

The forensic specimens were sealed, labeled, packaged and handed to Police Officer at Police Location and time.

Medical Management

Treatment

Investigation

Referral

Consultation

Discussion and Consultation:

I discussed my findings and the details of this case with:

- PolicePolice Officer's Name, Date

- Senior member of VIFM staff, Senior staff name, Date

Limitations to opinion

The opinion was made without obvious limitation. My opinion is limited by the following factors: (lighting, intubation, disability etc.)

DISCUSSION

Wound definition

Anatomical explanations

Concepts explained

OPINION

With respect to the above information and findings, I am of the opinion that:

Severity, Nature, Consequences, mechanism of injury, timing/ageing, etc.....

The opinions given in this statement are based on the information available to me and may be subject to change if further information becomes available.

Doctor's Full Name

Qualifications

Position Title

I hereby acknowledge that this statement is true and correct and I make it in the belief that a person making a false statement in the circumstances is liable to the penalties of perjury.

Doctor's Full Name

Qualifications

Position Title

Acknowledgment taken and signature witnessed by me at ………….am/pm

On………………………………, the…………………………day of………………………… [year]

at the ……………………………………………………………...

Signature …………………………………………………………….

Name …………………………………………………………….

Rank/No …………………………………………………………….